Transcutaneous Transducer Garments

Policy ID: E-21-020

Section: Durable Medical Equipment

Effective Date: May 01, 2020

Revised Date: May 23, 2023

Revision Effective Date: July 01, 2024

Last Reviewed: May 15, 2024

Applies To: Commercial and Medicaid Expansion

Description

Transcutaneous electrical nerve stimulation (TENS) and/or neuromuscular electrical stimulation (NMES) can ordinarily be delivered to individuals through the use of conventional electrodes, adhesive tapes and lead wires. There may be times, however, when it is medically necessary for certain individuals receiving TENS or NMES treatment to use a form-fitting conductive garment (i.e., a garment with conductive fibers which are separated from the individual's skin by layers of fabric). This conductive garment is worn as an alternative to conventional electrodes, adhesive tapes and lead wires.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

A form-fitting conductive garment and related supplies may be considered medically necessary when:

The garment has received permission or approval for marketing by the Food and Drug Administration; and
The garment has been prescribed by a physician for use in delivering covered TENS or NMES treatment; and
ANY ONE of the medical indications outlined below is met:
- The individual cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes and lead wires; or
- The individual cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; or
- The individual has a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires; or
- The individual requires electrical stimulation beneath a cast either to treat disuse atrophy, where the nerve supply to the muscle is intact, or to treat chronic intractable pain; or
- The individual has a medical need for rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury where the nerve supply to the muscle is intact.

A conductive garment is considered not medically necessary for use with a TENS device during the two month trial period unless:

There is documentation of a skin problem that existed prior to the start of the trial period; or
A medical review establishes that use of a conductive garment is medically necessary for the individual.

Procedure Code

E0731

Treatment of Muscle Atrophy

Functional neuromuscular electrical stimulation (NMES) may be considered medically necessary for treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse are causing atrophy.

NOTE: Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). NMES for any other indication is considered not medically necessary.

NMES for any other indication is considered not medically necessary.

Procedure Code

E0745

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 New Policy

Internal Medical Policy Committee 3-17-2021 Annual Review

Title change-removal of abbreviation.

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-23-2023 Revision with coding update - Effective July 03, 2023

Added criteria for NMES
Added procedure code E0745

Internal Medical Policy Committee 5-15-2024 Annual Review-no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-21-019

Section: Durable Medical Equipment

Effective Date: May 01, 2020

Revised Date: March 09, 2021

Revision Effective Date: May 03, 2021

Last Reviewed: March 23, 2023

Archived Date: July 02, 2023

Applies To: Commercial and Medicaid Expansion

Description

Transcutaneous electrical nerve stimulation (TENS) and/or neuromuscular electrical stimulation (NMES) can ordinarily be delivered to individuals through the use of conventional electrodes, adhesive tapes and lead wires. There may be times, however, when it is medically necessary for certain individuals receiving TENS or NMES treatment to use a form-fitting conductive garment (i.e., a garment with conductive fibers which are separated from the individual’s skin by layers of fabric). This conductive garment is worn as an alternative to conventional electrodes, adhesive tapes and lead wires.

Criteria

A form-fitting conductive garment and related supplies may be considered medically necessary when:

The garment has received permission or approval for marketing by the Food and Drug Administration; and
The garment has been prescribed by a physician for use in delivering covered TENS or NMES treatment; and
ANY ONE of the medical indications outlined below is met:
- The individual cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes and lead wires; or
- The individual cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; or
- The individual has a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires; or
- The individual requires electrical stimulation beneath a cast either to treat disuse atrophy, where the nerve supply to the muscle is intact, or to treat chronic intractable pain; or
- The individual has a medical need for rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury where the nerve supply to the muscle is intact.

A conductive garment is considered not medically necessary for use with a TENS device during the two month trial period unless:

There is documentation of a skin problem that existed prior to the start of the trial period; or
A medical review establishes that use of a conductive garment is medically necessary for the individual.

Procedure Codes

E0731

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 New Policy

Internal Medical Policy Committee 3-17-2021 Annual Review-title change-removal of abbreviation.

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Links

References (PDF)

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